HC - Utilization Review Nurse - Senior
The Judge Group Inc.

Job Info

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Location: REMOTE
Salary: Dependent on Experience
Description:
Judge Healthcare is currently seeking a Texas Licensed *REMOTE* Utilization Review Nurse for one of our top healthcare clients!

Position details:

• Location: REMOTE, but must have Texas RN license, or compact license

• Job Type: Ongoing contract
• Schedule: 9am - 6pm CST/ Monday - Friday and rotating Saturday shift

Job Description:

• Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines / criteria
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
• Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
• Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turnaround times
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information.
• Sends appropriate system-generated letters to provider and member
• May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
• Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department

.Job Requirements:

• Current, unrestricted Texas RN license or compact license
• 2+ years of experience in managed care OR 5+ years nursing experience
• Strong problem solving and analytical skills
• Proficient in PC Software computer skills
• Excellent communication skills both verbal and written skills
• Ability to interact productively with individuals and with multidisciplinary teams with minimal guidance
• Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
• Employees are required to screen for symptoms using the ProtectWell mobile app, Interactive VoiceResponse (i.e., entering your symptoms via phone system) or a similar approved symptom screener prior to entering the work site each day, in order to keep our work sites safe.
• Employees must comply with any state and local masking orders. In addition, when in the client building, employees are expected to wear a mask in areas where physical distancing cannot be attained

All interested and qualified candidates can apply directly to Paige Feldman at dbuchanan@judge.com or call Paige at (610) 617-1529 for immediate consideration.

Contact: dbuchanan@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

This job has expired.